Chronic kidney disease (CKD) is common in U.S. adults and is associated with excess mortality and morbidity. Better management could slow progression of disease, prevent metabolic complications, and reduce cardiovascular outcomes. However, low patient and provider awareness of CKD, inadequate knowledge of treatment strategies, and ineffective patient-provider communication can impede such efforts. We propose to evaluate an incrementally intensive set of interventions to enhance awareness, improve knowledge, and foster better communication, possibly leading to better clinical outcomes. The interventions, based on the Chronic Care Model and Social Cognitive Theory, will be evaluated in a high-risk, underserved population seeking primary care at 10 community health clinics, using a prospective randomized trial nested in a quasi- experimental study design. In four clinics, we will introduce an automated CKD registry incorporating decision support, which will identify patients with CKD, send notifications to providers, and provide educational materials to patients and providers (Basic CKD Registry). In six additional clinics, we will introduce the Enhanced CKD Registry, which will include all the components of the Basic CKD Registry, augmented with claims-based surveillance of care and care team feedback. We will randomize patients in these six clinics to either 1) the Enhanced CKD Registry intervention or 2) the Enhanced CKD Registry Plus, which includes an additional patient-level intervention: automated telephone calls offering CKD education and self-management support, with need-based follow-up by a health coach who communicates with the care team. We will compare our primary outcome, change in blood pressure, pre- vs. post-implementation of the Basic CKD Registry;between patients in the Enhanced vs. Basic CKD Registry;and between patients in the Enhanced CKD Registry Plus vs. the Enhanced CKD Registry. We will also examine secondary clinical (e.g., albuminuria, HbA1c), intermediate (e.g., awareness, activation, ACE/ARB use), and sustainability (e.g., reach, adoption, maintenance) outcomes. This proposal unites a large safety-net health system for patients at high risk for CKD progression and complications to address barriers to improved CKD management. Successful interventions can be extended throughout our larger healthcare system, on a wider scale in similar safety-net systems, and in patient populations with less complex clinical profiles. Thus, this study has important implications for improving the health status of CKD patients in the United States. PUBLIC HEALTH RELEVANCE: Chronic kidney disease, which is associated with significant morbidity and mortality, is highly prevalent in the United States, particularly among underserved populations. Improving disease awareness and health communication and maintaining active surveillance through tailored, proactive health IT can improve health outcomes among patients with CKD via activation of patients and providers and engagement in risk-reduction behaviors.